Anterior Cruciate Ligament Quality Of Life Research Articles

Clinical outcomes of primary anterior cruciate ligament reconstruction using six-strand hamstring autograft

Objectives: Quadrupled and five-strand hamstring tendon (HT) autografts are commonly used in anterior cruciate ligament reconstruction (ACLR), but there is significant variability in graft diameter. The six-strand HT autograft has been introduced to increase graft diameter in patients with undersized HT grafts and may achieve better clinical outcomes. None of the studies has reported clinical outcomes following this technique in Indian patients. We investigated clinical outcomes in patients who underwent primary ACLR using a six-strand HT autograft technique with a minimum six-month follow-up. Materials and Methods: Fifty-five patients who underwent primary ACLR using six-strand HT autografts with interference screw fixation were included in the study. These patients were followed up at three and six months for the evaluation of clinical outcomes. Subjective evaluations included the TegnerLysholm score, anterior cruciate ligament-quality-of-life (ACL-QOL) score, and International Knee Documentation Committee (IKDC) subjective score. Laxity assessments of the knees were performed using the Lachman test and the pivot-shift test. Functional evaluation of the patients was performed with an overall IKDC objective score. Results: The mean IKDC subjective score was significantly improved at three-month (63.42 ± 5.38) and six-month (82.82 ± 7.49) follow-up after surgery (P < 0.05) when compared with pre-operative scores (50.55 ± 1.84). A similar finding was also noted with the Tegner-Lysholm score and ACL-QOL score in our study. All patients have achieved normal to near-normal functional outcomes at six months in our study without any major complications. The most commonly found complication was paresthesia (21.80%) in the present study. Conclusion: In the primary ACLR, six-strand hamstring autograft achieves similar clinical outcomes and complications as reported with four-strand or five-strand HT autografts. However, the percentages of patients who achieved normal to near-normal outcomes were higher in the present study (100%) as compared to earlier reported data using four-strand or five-strand HT autografts (~85%). The six-strand graft technique is a useful means of increasing graft diameter when faced with an undersized hamstring graft.

Spanish Version of the Anterior Cruciate Ligament-Quality of Life Questionnaire: Translation, Cross-cultural Adaptation, and Validation.

The Anterior Cruciate Ligament-Quality of Life (ACL-QOL) questionnaire is a patient-reported outcome measure used to assess the effect of an anterior cruciate ligament (ACL) injury on the lives of patients. It was originally written in English, which may affect its use when completed by nonnative English speakers. To translate and adapt the ACL-QOL to Spanish and provide evidence of its psychometric properties. Cohort study (diagnosis); Level of evidence, 2. A total of 183 patients with an ACL injury from 4 Catalan hospitals were included: 99 patients who had undergone ACL reconstruction (ACLR) completed the Spanish version of the ACL-QOL (ACL-QOL-Sp) twice (mean interval, 15.2 days) in 2 weeks for test-retest reliability, and 84 patients completed the ACL-QOL-Sp, the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale, and the 12-item Short Form Health Survey (SF-12) before and at 4 and 9 months after ACLR to assess responsiveness. The association between the ACL-QOL-Sp and the other outcome measures was evaluated with the Spearman correlation coefficient. The ACL-QOL-Sp showed good internal consistency (Cronbach alpha = 0.96) and test-retest reliability (intraclass correlation coefficient = 0.97). The standard error of measurement was 3.6, also suggesting the precision of measurements. The smallest detectable change was 9.98 in 94% of patients. No association was found between the ACL-QOL-Sp score and the Tegner score or SF-12 mental component summary score; however, a moderate correlation was found with the overall KOOS score (r = -0.545), Lysholm score (r = 0.509), and SF-12 physical component summary score (r = 0.607). The correlation ranged from weak for the KOOS-Symptoms subscore (r = -0.290) to moderate for the KOOS-Quality of Life subscore (r = -0.698). No ceiling or floor effects were observed. The ACL-QOL-Sp showed a moderate effect size (0.73) at 4 months but a large effect size (1.70) at 9 months. The ACL-QOL-Sp showed adequate internal consistency, test-retest reliability, and responsiveness in evaluating quality of life after ACLR in Spanish-speaking patients.

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol

ObjectiveInvestigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP).MethodsEighty consecutive patients...

Translation and Validation of a Simplified Chinese Version of the Anterior Cruciate Ligament–Quality of Life Questionnaire

Background: The Anterior Cruciate Ligament–Quality of Life (ACL-QOL) questionnaire is a widely used and effective scale for quality of life in patients with chronic anterior cruciate ligament (ACL) injury. Purpose: To translate and adapt the ACL-QOL questionnaire for Chinese patients and evaluate its reliability, validity, and responsiveness in this population. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Translation and adaptation were conducted in accordance with the guidelines of the A merican Academy of Orthopaedic Surgeons Outcome Committee. Included were 121 patients who were diagnosed with a chronic ACL injury and underwent ACL reconstruction between January 2020 and June 2021. Preoperatively, patients completed the simplified Chinese version of the ACL-QOL (ACL-QOL-C), the Knee injury and Osteoarthritis Outcome Score, and the 12-Item Short Form Health Survey. The ACL-QOL-C was also completed at 12- and 24-week follow-ups. Psychometric evaluations were then performed and included score distribution, internal consistency, test-retest reliability, construct validity, and responsiveness. Results: The Cronbach alpha ranged from .905 to .975, indicating excellent internal consistency, and the intraclass correlation coefficient ranged from 0.864 to 0.985, indicating excellent test-retest reliability. The consistency between the above results and our a priori hypotheses was more than 70% (35/42), indicating good construct validity. The standard error of measurement and effect size of the total score and each item of the ACL-QOL-C were >0.8 at the final follow-up, indicating good responsiveness. Conclusion: The English version of the ACL-QOL has been successfully translated into Chinese, and it has been shown to be applicable for the assessment of the quality of life in Chinese patients with chronic ACL injury.

Variables associated with successful outcome after anterior cruciate ligament reconstruction in recreational athletes: A prospective cohort study

BackgroundAnterior cruciate ligament (ACL) injury and subsequent reconstruction is common and has a profound effect on health-related quality of life. There is currently limited understanding as to which variables are associated with a successful outcome post-ACL reconstruction (ACLR) in recreational athletes. PurposeExplore the association between both patient-reported and performance-based measures, and successful outcome, post-ACLR in recreational athletes. ProceduresWe sought to recruit recreational athletes within one month of a primary-ACLR for a prospective cohort study. A dichotomised patient specific functional scale of ≥9 points determined a successful outcome at nine-months post-operative. Secondary patient-reported and performance-based data were collected at baseline, three-, six-, and nine-months post-operative. The association between secondary data and the primary outcome was determined using binomial logistic regression, expressed using odds ratio (OR) and 95% confidence intervals (CI). Main results90 participants were recruited (males: 58, females: 32, mean age 32.8 years [±7.9], mean height 173.5 [±10.0], mean body mass 74.0 kg [±15.8]), 87 consented to baseline measures. 47 participants completed full data collection and 21 (45%) reported a successful outcome. Higher knee osteoarthritis outcome score (OR range 1.07–1.12) and anterior cruciate ligament quality of life (ACL-QoL) scores (OR range 1.06–1.10) were associated with a successful outcome post-ACLR at various timepoints. ConclusionsPatient-reported, rather than performance-based, measures were associated with successful outcome nine-months post-ACLR in recreational athletes. Both patient-reported and performance-based characteristics are advocated to guide optimal return to function in clinical practice.

Translation, Validity, and Reliability of the Dutch Anterior Cruciate Ligament-Quality of Life Questionnaire.

Background:The Anterior Cruciate Ligament–Quality of Life (ACL-QoL) questionnaire is a valid and reliable injury-specific instrument to assess the impact of an ACL rupture on the daily life of a patient.Purpose:To translate the ACL-QoL into Dutch (ACL-QoL-NL) and to study its psychometric properties in patients with an ACL rupture.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:The original ACL-QoL questionnaire was translated from English to Dutch according to international guidelines. The study population consisted of 122 patients with a confirmed ACL rupture who completed the ACL-QoL-NL as well as 4 questionnaires: the International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, 36-item Short Form Health Survey, and Lysholm Knee Score. We determined the internal consistency, construct validity, and prevalence of floor and ceiling effects of the ACL-QoL-NL total score as well as its 5 subscales. To determine test-retest reliability, we analyzed the data of 68 patients who had a stable knee condition and who completed the ACL-QoL-NL a second time after a 2-week interval.Results:The confirmatory factor analysis showed that the original structure of the ACL-QoL-NL was confirmed, except for 4 of 31 items. Internal consistency of the total scale and all 5 subscales was good. More than 75% of the predefined hypotheses on the correlations between the ACL-QoL-NL and the 4 questionnaires were met, indicating good construct validity. No significant floor or ceiling effects were observed. Test-retest reliability was good, and no systematic bias between test and retest was found. Standard error of measurement for the total score was 4.8 points out of 100, and the smallest detectable changes at the group and individual levels were 1.6 and 13.2 points, respectively.Conclusion:The ACL-QoL-NL questionnaire was successfully translated from English to Dutch and demonstrated good internal consistency, validity, and reliability, with no presence of floor or ceiling effects.

Validity, Responsiveness, and Reliability of the ACL-QOL in an Adolescent Population.

The anterior cruciate ligament quality of life (ACL-QOL) score is a disease-specific patient-reported outcome measure that assesses patients with ACL deficient and reconstructed knees. The ACL-QOL has demonstrated validity, responsiveness, and reliability in adult populations but has yet to be specifically evaluated in adolescent patients. The purpose of this study was to assess the validity, responsiveness, and reliability of the ACL-QOL in an adolescent population. Between 2010 and 2015, questionnaires from 294 consecutive adolescent patients consented for an ACL reconstruction were collected from an orthopaedic sport medicine clinic. The ACL-QOL was administered preoperatively, and at 6, 12, and 24 months following primary ACL reconstruction. To assess content validity, the Cronbach α and floor and ceiling effects were measured. Question reading level was measured with an online tool (https://readable.com/). Responsiveness was assessed with a 1-way analysis of variance to compare the preoperative and postoperative time periods. A test-retest strategy with completion of the ACL-QOL twice within 3 weeks was used to assess reliability using an intraclass correlation coefficient (ICC 2,k) and the SEM. The ACL-QOL demonstrated high content validity with a Cronbach αbetween 0.93 and 0.97, with no evidence of floor or ceiling effects at any study time point. The mean readability grade level was calculated to be 6.9, along with a readability score of 68. The ACL-QOL scores revealed a statistically significant improvement over time (P<0.001) with a Cohen d of 0.56, indicating a large effect size. Test-retest reliability revealed an ICC (2,k) of 0.997 (95% confidence interval=0.992-0.999). The ACL-QOL demonstrated content validity, responsiveness to change, and reliability in an adolescent ACL reconstruction population. The readability of the ACL-QOL is acceptable for adolescents with an ACL injury. The ACL-QOL is a valid, responsive, and reliable patient-reported outcome measure that can be used in an adolescent population with ACL deficiency or following ACL reconstruction. Level III.

Prognostic Factors for Patient-Reported Outcomes at 32 to 37 Years After Surgical or Nonsurgical Management of Anterior Cruciate Ligament Injury.

Background:Knowledge to inform the identification of individuals with a poor long-term prognosis after anterior cruciate ligament (ACL) injury is limited. Identifying prognostic factors for long-term outcomes after ACL injury may inform targeted interventions to improve outcomes for those with a poor long-term prognosis.Purpose:To determine whether ACL treatment (early augmented or nonaugmented ACL repair plus rehabilitation, rehabilitation alone, or rehabilitation plus delayed ACL reconstruction [ACLR]) and 4-year measures (quadriceps and hamstrings strength, single-leg hop, knee laxity, flexion and extension deficit, self-reported knee function, activity level) are prognostic factors for patient-reported outcomes at 32 to 37 years after acute ACL injury.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 251 patients aged 15 to 40 years with acute ACL rupture between 1980 and 1985 were allocated to early ACL repair (augmented or nonaugmented) plus rehabilitation or to rehabilitation alone, based on birth year. One hundred ninety of 234 completed 32- to 37-year follow-up questionnaires (response rate, 81%); 18 people were excluded, resulting in 172 patients available for analysis (mean age, 59 ± 6 years; 28% female). Potential prognostic factors assessed 4 years after ACL injury were ACL treatment (early ACL repair, rehabilitation alone, or delayed ACLR), isokinetic quadriceps and hamstrings strength, single-leg hop performance, knee flexion and extension deficit, knee laxity, Tegner activity scale, and Lysholm score. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the Anterior Cruciate Ligament Quality of Life (ACL-QOL) measure. Linear regression adjusted for age, sex, baseline meniscal injury, and contralateral ACL injury was used to assess potential prognostic factors for 32- to 37-year outcomes. Multiple imputation accounted for missing data.Results:A fair/poor Lysholm score (vs excellent/good) at 4 years was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −12 [95% confidence interval (CI), −19 to −4]), KOOS Symptoms (−15 [95% CI, −23 to −7]), KOOS Sport and Recreation (−19 [95% CI, −31 to −8]), and ACL QOL (−9 [95% CI, −18 to −1]) scores. A 4-year single-leg hop limb symmetry index <90% was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −9 [95% CI, −17 to −1]) and ACL QOL (−13 [95% CI, −22 to −3]) scores at long-term follow-up. A lower activity level, delayed ACLR, and increased knee laxity were prognostic factors in the crude analysis. Rehabilitation alone versus early repair, quadriceps and hamstring strength, and flexion and extension deficit were not related to 32- to 37-year outcomes.Conclusion:Reduced self-reported knee function and single-leg hop performance 4 years after ACL injury were prognostic factors for worse 32- to 37-year outcomes. Estimates exceeded clinically important thresholds, highlighting the importance of assessing these constructs when managing individuals with ACL injuries.Registration:NCT03182647 (ClinicalTrials.gov identifier).

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study.

Background:A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)–injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined.Purpose:To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs).Study Design:Cross-sectional study; Level of evidence, 3.Methods:A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot.Results:Six factors were associated with a high-grade pivot shift: Beighton score (each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30; P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13; P = .005), presence of a posterior third medial (OR, 2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95% CI, 1.01-3.08; P = .048) meniscal injury, tibial slope >9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope <9° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14; P = .04); however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores.Conclusion:Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at 5-Year Follow-up.

This randomized clinical trial evaluated the 5-year, disease-specific quality-of-life outcomes of patients treated for anterior cruciate ligament (ACL) deficiency with use of a patellar tendon, single-bundle quadruple-stranded hamstring, or double-bundle hamstring reconstruction. Patients (n = 110 per group; 183 male; 14 to 50 years of age) were randomly allocated to anatomically positioned ACL reconstruction with use of a patellar tendon graft (patellar tendon group; mean age, 28.7 years), quadruple-stranded hamstring tendon construct (hamstring tendon group; mean age, 28.5 years), or double-bundle hamstring tendon construct (double-bundle group; mean age, 28.3 years). Computer-generated allocation with varied block randomization was performed intraoperatively. The 5-year primary outcome measure was the Anterior Cruciate Ligament-Quality of Life (ACL-QOL) score, and secondary outcome measures included the International Knee Documentation Committee (IKDC) subjective score and objective grades, pivot shift assessment, range of motion, kneeling pain, Tegner activity scale, Cincinnati Occupational Rating Scale, complete traumatic reruptures, partial traumatic tears, total traumatic reinjuries, and atraumatic graft failures. Three hundred and fifteen patients (95%) completed the 5-year follow-up (4 withdrawals, and 11 lost to follow-up). ACL-QOL scores increased significantly from baseline for all groups (p < 0.0001), but mean scores at 5 years did not differ among the groups (p = 0.548): mean (and standard deviation) of 82.5 ± 17.9 (95% confidence interval [CI], 79.0 to 86.0) for patellar tendon, 83.9 ± 18.2 (95% CI, 80.3 to 87.4) for hamstring tendon, and 81.1 ± 19.3 (95% CI, 77.4 to 84.8) for double-bundle. The proportions of patients at 5 years with a pivot shift grade of ≥2 (12% for patellar tendon, 16% for hamstring tendon, and 22% for double-bundle; p = 0.149) and with normal and nearly normal knees per IKDC grade (87%, 82%, and 75% for the 3 groups, respectively; p = 0.093) trended in favor of patellar tendon reconstruction. No differences were seen for the IKDC subjective scores, knee range of motion including passive extension deficits, the single leg hop test, Cincinnati Occupational Rating scores, and Tegner activity levels. Kneeling pain was more common with patellar tendon reconstruction (10% of patients compared with 4% for hamstring tendon and 2% for double-bundle; p = 0.029). For hamstring tendon and double-bundle reconstructions, there were trends toward more complete traumatic reruptures (4% for patellar tendon, 10% for hamstring tendon, and 10% for double-bundle; p = 0.145) and partial traumatic tears (0%, 5%, and 6%, respectively; p = 0.059), with significantly fewer combined traumatic reinjuries in the patellar tendon group (4 patients compared with 16 for hamstring tendon and 17 for double-bundle; p = 0.010). Atraumatic graft failure (pivot shift grade of ≥2) was found for 10% of the patients. At 5 years, we found no significant difference in the quality-of-life outcome among the patellar tendon, hamstring tendon, and double-bundle techniques for ACL reconstruction. Significantly more patients in the hamstring tendon and double-bundle groups experienced traumatic graft reinjury compared with the patellar tendon group. There was a trend toward a higher percentage with normal and nearly normal IKDC grades in the patellar tendon group compared with hamstring tendon and double-bundle groups. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Predictors Of Outcome Following Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study In Uk Sports Medicine

Background/Aims Following anterior cruciate ligament reconstruction, patients are reported to be at greater risk of re-rupture if they fail to meet structured discharge criteria. This prospective cohort study aimed to provide objective and subjective measures guiding safe return to play of amateur athletes following anterior cruciate ligament reconstruction. Methods Primary anterior cruciate ligament reconstruction patients presenting to Pure Sports Medicine were invited to participate. Successful return to play was determined using the Patient-Specific Functional Scale at the primary end point (9/12 post-operative), with scores &gt;8 indicating successful outcomes. Secondary data were collected at baseline (Knee Injury and Osteoarthritis Outcome Score, Anterior Cruciate Ligament-Quality of Life), 3/12 (Knee Injury and Osteoarthritis Outcome Score, Anterior Cruciate Ligament-Quality of Life, quadriceps and hamstrings dynamometry), 6/12 (Knee Injury and Osteoarthritis Outcome Score, Anterior Cruciate Ligament-Quality of Life, quadriceps and hamstrings dynamometry, single/triple hop) and 9/12 post-operative (Knee Injury and Osteoarthritis Outcome Score, Anterior Cruciate Ligament-Quality of Life, quadriceps and hamstrings dynamometry, single/triple hop and slalom run). Binary logistic regression was used to determine the association between secondary data and the primary outcome. Results A total of 90 participants with anterior cruciate ligament reconstruction were recruited from March 2017 to June 2018, and 87 participants consented to baseline measures. To date, 29 participants have completed full data collection, with 12 participants determined to have a successful outcome. A lower hamstrings:quadriceps ratio in the contralateral limb at 3/12 post-operative (odds ratio: 0.005, 95% confidence interval: 0.001–0.89, P=0.045) and a higher Anterior Cruciate Ligament-Quality of Life score at 6/12 post-operative (odds ratio: 1.1, 95% confidence interval: 0.02–1.20, P=0.012) are associated with positive 9/12 post-operative outcomes. Conclusions Preliminary data analysis indicates that both hamstrings:quadriceps ratio function and participant psychology are associated with positive outcomes post-anterior cruciate ligament reconstruction.

Translation, cross-cultural adaptation, reliability and validity of the Persian version of the ACL-QOL questionnaire in patients with anterior cruciate ligament reconstruction

BackgroundQuality of life (QOL) measures can be used to make sound clinical decisions after reconstruction of the anterior cruciate ligament (ACL). The purpose of the present study was to translate and cross-culturally adapt the Anterior Cruciate Ligament Quality of Life (ACL-QOL) questionnaire into the Persian language and to evaluate its psychometric properties. MethodsThe process of translation and cross-cultural adaptation followed the World Health Organization method. One hundred and forty-five patients with ACL reconstruction (ACL-R) filled out the Persian versions of ACL-QOL and the SF-36 Questionnaire. The measurement properties of internal consistency, agreement, criterion validity, floor and ceiling effects were measured. 40 out of 145 patients with ACL-R completed the Persian version of the ACL-QOL questionnaire twice for the test-retest reliability. ResultsThe questionnaire had high internal consistency (Cronbach's α = 0.96). The intraclass correlation was excellent for reliability and agreement in five domains and overall score (ICC 0.87, 0.74, 0.90, 0.85, 0.81 and 0.89; p < 0.001). The standard error of measurement and the minimum detectable change were found to be 3.28 points and 9.9 points, respectively. There was a strong correlation between each item and the total score of the Persian version of ACL-QOL questionnaire. The questionnaire showed strong and moderate criterion validity (r = 0.61, r = 0.37) with SF-36 physical component score and mental component score, respectively. No ceiling and floor effects were observed. ConclusionsPersian version of the ACL-QOL questionnaire has acceptable reliability and validity and can be used in assessing Iranians quality of life after ACL reconstruction.

No clinical differences between anteromedial portal and transtibial technique for femoral tunnel positioning in anterior cruciate ligament reconstruction: a prospective randomized, controlled trial.

The anteromedial (AMP) portal technique was introduced to position the femoral tunnel in anterior cruciate ligament (ACL) reconstruction to more closely replicate the original ACL footprint compared to the transtibial (TT) approach. Few randomized trials have evaluated differences in these techniques with respect to clinical outcomes. The purpose of this study was to determine if there are any differences in clinical outcome between the AMP and TT approaches. This is a single-blinded, prospective, randomized controlled trial. Participants were randomized to undergo ACL reconstruction using the AMP or TT approach. The primary outcome measure was the ACL quality of life (ACL-QOL), and secondary outcomes were the IKDC knee assessment, side-to-side difference in anterior-posterior knee laxity (KT-1000) and tunnel orientation (X-ray findings) at preoperative, 3, 6, 12, and 24months postoperative. Statistical comparisons were performed using a series of t tests for independent groups with equal variance. Ninety-six participants were consented and randomized between 2007 and 2011 with eight excluded postrandomization. Mean (SD) preoperative ACL-QOL was 33 (13) for TT and 36 (17) for AMP and improved significantly (p<0.001) in both groups to 79 (18) and 78 (18) at 24months postoperative, respectively. The preoperative median IKDC grade for both groups was C and improved similarly in both groups at 24months (n.s.). There was no side-to-side difference in knee laxity based on KT-1000 measurements with a mean (SD) 1 (3) mm between affected and unaffected limbs in the TT group compared to 1 (3) mm for the AMP group. A significant difference was found in femoral tunnel orientation with the AMP group at 43° (7) and the TT group 58° (8) in the coronal plane (p<0.001). No differences in clinical outcome were found when comparing AMP to TT in primary ACL reconstruction using a STG graft. This prospective randomized controlled trial suggests surgeons can use either method without significantly compromising clinical outcome. I.

A Randomized Trial Comparing Patellar, Hamstring and Double-bundle ACL Reconstruction at 5-yrs

Objectives:This prospective, double-blind RCT compares ACL reconstruction using patellar tendon, quadruple hamstring and double-bundle hamstring grafts, by measuring patient-reported disease-specific quality of life outcome in patients with isolated ACL deficiency of the knee at a 5-years post-op.Methods:Patients (n=330; 183 males, 147 females) aged 14-50 years were randomly allocated and equally distributed to one of three anatomic ACL autograft reconstruction techniques: 1) Patellar Tendon (PT; mean age 28.7 years), 2) Quadruple-stranded Hamstring Tendon (HT; mean age 28.5 years), or 3) Double-Bundle using hamstring tendons (DB; mean age 28.3 years). Computer-generated allocation with varied block randomization was performed intra-operatively. Outcomes were measured at baseline, 3 and 6 months, 1, 2 and 5 years. Two-year results were previously reported. Primary outcome: Anterior Cruciate Ligament Quality-of-Life (ACL-QOL). Secondary outcomes: International Knee Documentation Committee (IKDC) subjective score and objective grades, pivot shift, range of motion, kneeling pain, Tegner activity level, and the Cincinnati Occupational Rating Scale. The proportion of re-ruptures, partial re-ruptures and the combined total traumatic re-injuries were compared. Radiographic evaluation was performed at baseline, 2 and 5 years; this analysis is ongoing. A 5% significance level was used for all outcomes.Results:315 randomized patients (95%) d 5-yr follow-up. There were 4 withdrawals and 11 patients lost-to-follow-up. Baseline characteristics between the groups were not different. ACL-QOL scores increased significantly from baseline over time for all groups (p=0.000). There was no difference in mean ACL-QOL score at 5-years (p=0.548): PT=82.5 (SD 17.9, 95% CI 79.0-86.0); HT=83.9 (SD 18.2, 95% CI 80.3-87.4); DB=81.1 (SD 19.3, 95% CI 77.4-84.8). At 5-years, there were no differences in the proportion of patients with a Pivot Shift grade 2 or greater (p=0.106): PT=11/98 (11%); HT=16/99 (16%); DB=23/103 (22%). Mean IKDC subjective scores were not different between groups at 5-yrs (p=0.770): PT=83.9 (SD 12.9, 95% CI = 81.4-86.5); HT=85.2 (SD 13.0, 95% CI = 82.7-87.7); DB=84.3 (SD 13.4, 95% CI = 81.7-86.9). Based on IKDC objective grades, the proportions of Normal/Nearly Normal knees at 5-years were not different between groups: PT=85/98 (87%); HT=82/99 (81%); DB=75/103 (76%), p=0.093. 5-yr Tegner activity levels and Cincinnati Occupational Scores were also not different between the groups (p=0.872 and p=0.813, respectively). Kneeling pain remained more common in the PT group (PT=10/98; HT 4/98; DB 2/101; p=0.029). More traumatic graft ruptures occurred in the HT and DB groups (PT=4/103; HT=11/105; DB=11/107; p=0.145). Revision ACL reconstructions were performed on 22 of these patients. There were an additional 11 partial graft re-ruptures (PT=0; HT=5; DB=6), with less total traumatic re-injuries in the patellar tendon group (PT=4; HT=16 and DB=17, p=0.010). Four patients had additional surgery to the index knee, not including the revision surgery between the 2 and 5-yr follow-up.Conclusion:At 5 years, there was no difference in disease-specific quality-of-life outcome or IKDC grades between the PT, HT and DB techniques for ACL reconstruction. There were significantly more traumatic graft re-injuries in the HT and DB groups compared to the PT group.

TUNNEL POSITIONING IN REMNANT SPARING DOUBLE BUNDLE ACL RECONSTRUCTION — A 2-YEAR STUDY OF MRI TUNNEL POSITIONS, CLINICAL OUTCOMES AND TUNNEL CONFLUENCE

Purpose: The purpose of this study is to examine the outcomes of a cohort of patients who have undergone a new surgical technique for anterior cruciate ligament (ACL) tunnel targeting using the footprint of the torn ACL as soft tissue markers. This is in the setting of anatomical ACLR with remnant preservation. Methods: This retrospective single center cohort study was conducted on patients undergoing a primary ACLR between August 2008 and February 2013. A total of 103 patients underwent ACLR with a remnant sparing technique with non-radiological soft tissue targeting of femoral and tibial tunnels. Exclusion criteria included skeletal immaturity, concomitant meniscal repair or ligament surgery, knee malalignment, delayed presentation ([Formula: see text]6 months post injury) and incomplete medical insurance. At 2 years all patients had gadolinium MRI scan, plain film X-ray, and a clinical assessment including KT-1000 arthrometry, and the following outcome scores; Tegner, IKDC (subjective/objective), Lysholm, Cincinnati and ACL Quality of Life. Results: A total of 44 patients (18 males, 26 females; mean age 30.9 years [Formula: see text]/[Formula: see text]11.8) were enrolled within the study. About 93.2% of the participants achieved an IKDC objective rating of A or B. The mean scores for outcome measures were; IKDC Subjective (84.9[Formula: see text][Formula: see text]/[Formula: see text][Formula: see text]11), Tegner (6.1[Formula: see text][Formula: see text]/[Formula: see text][Formula: see text]2), Lysholm (87.2[Formula: see text][Formula: see text]/[Formula: see text][Formula: see text]11.3), Cincinnati (358.1[Formula: see text][Formula: see text]/[Formula: see text][Formula: see text]40.8) and ACL Quality of Life (75.4[Formula: see text][Formula: see text]/[Formula: see text][Formula: see text]19). There were no graft failures at follow up. No patients had a loss of full extension [Formula: see text]. All tunnels were positioned satisfactorily. Almost half of all femoral tunnels (47.8%) and 30.4% of tibial tunnels were confluent at the joint surface. Conclusions: This series demonstrates that anatomical double tunnel ACLR using non-radiological guided remnant retention technique, provides satisfactory 2-year clinical outcomes and is a safe and effective option. Targeting tunnels to be within the native remnant leads to high rates of tunnel confluence.

Anterior Cruciate Ligament Quality of Life (ACL-QOL) Questionnaire: Responsiveness to Change up to 2-years post ACL Reconstruction

IntroductionThe ACL-QOL was originally published by Mohtadi in 1998, and has been cited in over 130 studies. The responsiveness to change of an instrument is one aspect of its validity. The purpose of this study was to further validate the ACL-QOL by assessing its responsiveness to change up to 2-years post anterior cruciate ligament (ACL) reconstruction surgery.MethodsFive hundred and seventy nine ACL-deficient patients were referred to an orthopaedic surgical practice for consultation. All patients completed the ACL-QOL questionnaire pre-operatively (n = 579). Data was prospectively gathered from this patient cohort 6-months post-operatively (n = 446), 12-months post-operatively (n = 280), and 24-months post-operatively (n= 100). Comparison of change in ACL-QOL scores was calculated using a one-way analysis of variance (ANOVA) for each time point.ResultsThe mean ACL-QOL score for ACL-deficient patients presenting for an orthopaedic surgery consultation was 35.6/100, (n = 579). The mean post-operative ACL-QOL scores were 51.5/100 at 6-months (n = 446), 67.3/100 at 12-months (n = 280) and 81.5/100 at 24-months (n =100). There was a statistically significant difference in ACL-QOL scores from the initial orthopaedic consult, to the 6-month, 12-month and 24-month post-operative appointments, p < 0.001. There was a statistically significant difference between the mean ACL-QOL scores at 6, 12 and 24 months post-operatively p < 0.005.ConclusionThis study provides further validation of the ACL-QOL by demonstrating the responsiveness to change of this disease-specific quality of life instrument. Patients demonstrated a statistically significant improvement in ACL-QOL score following ACL reconstruction surgery. IntroductionThe ACL-QOL was originally published by Mohtadi in 1998, and has been cited in over 130 studies. The responsiveness to change of an instrument is one aspect of its validity. The purpose of this study was to further validate the ACL-QOL by assessing its responsiveness to change up to 2-years post anterior cruciate ligament (ACL) reconstruction surgery. The ACL-QOL was originally published by Mohtadi in 1998, and has been cited in over 130 studies. The responsiveness to change of an instrument is one aspect of its validity. The purpose of this study was to further validate the ACL-QOL by assessing its responsiveness to change up to 2-years post anterior cruciate ligament (ACL) reconstruction surgery. MethodsFive hundred and seventy nine ACL-deficient patients were referred to an orthopaedic surgical practice for consultation. All patients completed the ACL-QOL questionnaire pre-operatively (n = 579). Data was prospectively gathered from this patient cohort 6-months post-operatively (n = 446), 12-months post-operatively (n = 280), and 24-months post-operatively (n= 100). Comparison of change in ACL-QOL scores was calculated using a one-way analysis of variance (ANOVA) for each time point. Five hundred and seventy nine ACL-deficient patients were referred to an orthopaedic surgical practice for consultation. All patients completed the ACL-QOL questionnaire pre-operatively (n = 579). Data was prospectively gathered from this patient cohort 6-months post-operatively (n = 446), 12-months post-operatively (n = 280), and 24-months post-operatively (n= 100). Comparison of change in ACL-QOL scores was calculated using a one-way analysis of variance (ANOVA) for each time point. ResultsThe mean ACL-QOL score for ACL-deficient patients presenting for an orthopaedic surgery consultation was 35.6/100, (n = 579). The mean post-operative ACL-QOL scores were 51.5/100 at 6-months (n = 446), 67.3/100 at 12-months (n = 280) and 81.5/100 at 24-months (n =100). There was a statistically significant difference in ACL-QOL scores from the initial orthopaedic consult, to the 6-month, 12-month and 24-month post-operative appointments, p < 0.001. There was a statistically significant difference between the mean ACL-QOL scores at 6, 12 and 24 months post-operatively p < 0.005. The mean ACL-QOL score for ACL-deficient patients presenting for an orthopaedic surgery consultation was 35.6/100, (n = 579). The mean post-operative ACL-QOL scores were 51.5/100 at 6-months (n = 446), 67.3/100 at 12-months (n = 280) and 81.5/100 at 24-months (n =100). There was a statistically significant difference in ACL-QOL scores from the initial orthopaedic consult, to the 6-month, 12-month and 24-month post-operative appointments, p < 0.001. There was a statistically significant difference between the mean ACL-QOL scores at 6, 12 and 24 months post-operatively p < 0.005. ConclusionThis study provides further validation of the ACL-QOL by demonstrating the responsiveness to change of this disease-specific quality of life instrument. Patients demonstrated a statistically significant improvement in ACL-QOL score following ACL reconstruction surgery. This study provides further validation of the ACL-QOL by demonstrating the responsiveness to change of this disease-specific quality of life instrument. Patients demonstrated a statistically significant improvement in ACL-QOL score following ACL reconstruction surgery.

Return to sport and quality of life in people with knee symptoms 5–20 years following anterior cruciate ligament reconstruction

Introduction:Anterior cruciate ligament reconstruction (ACLR) can result in psychological and physical impairments that impact on participation in desired activities and sports. To date, no study has explored the impact of sports restrictions on quality of life (QOL) in people with knee symptoms following ACLR. The aims of this study were to (i) quantify QOL; and (ii) explore relationships between participant characteristics, sport-related factors and QOL 5–20 years following ACLR. Methods: We conducted a cross-sectional analysis on 139 individuals with knee pain, stiffness or activity limitations 5–20 years following ACLR. Participants were recruited from surgical records of four experienced orthopaedic surgeons. All patients aged 18–55 years who had a hamstring or patellar-tendon autograft ACLR 5–20 years ago were invited to participate. People with significant comorbidities and those not fluent in English were excluded. Participants completed the Anterior Cruciate Ligament QOL Questionnaire (ACL-QOL), Knee injury andOsteoarthritis Outcome Score (KOOS) and a demographics questionnaire. KOOS and ACL-QOL scores range from 0 (worst) to 100 (best). KOOS cut-off criteria were applied to ensure all participants were symptomatic. Spearman rank correlations explored relationships between participant characteristics, return to sports information and QOL. Results: A total of 139 participants completed the questionnaires at a mean 9 years (range 5–20) following ACLR. Participants had a mean age of 38 years (range 20–55), a mean BMI of 27 (range 19–43) and 42% were female. Participants scored a mean 55±20on theKOOS-QOL subscale and57±21on theACL-QOL. The most impaired ACL-QOL itemswere sport/recreational frustrations (33±31), playing sport under caution (36±35) and fear of contact sports (35±37). The least impaired ACL-QOL subscale was workrelated concerns (78±22). Returning to sport at a lower level (27%) or not returning to sport (34%) was correlated with poor KOOSQOL scores (r=0.32, p<0.01). Reporting the knee as the reason for not returning to the same level of sport (77%) was correlated with competitive needs not being met (r=0.25, p=0.01) and poor knee confidence (r=0.20, p=0.05). Pain-free sport or exercise participation was considered preferable (78%) to pain-free participation in work (2%), family (15%) or social activities (5%). Discussion: The ability to participate in sport and exercise appear to be a high priority and is associatedwith QOL impairment in peoplewith knee symptoms 5–20 years after ACLR. Knee-related QOL was considerably lower than population norms. Addressing knee confidence, sport-related concerns, frustrations and fearsmay assist in improving QOL following ACLR.

Turkish version of the Anterior Cruciate Ligament Quality of Life questionnaire.

To test the measurement properties of Turkish version of the Anterior Cruciate Ligament Quality of Life (ACL-QOL) questionnaire. One hundred and nineteen patients with ACL reconstruction (ACL-R) completed internal consistency, agreement, construct validity, floor and ceiling effect analyses. Eighty out of 119 patients with ACL-R completed Turkish version of the ACL-QOL questionnaire twice for the test-retest reliability. A subgroup of thirty-nine patients undergoing physiotherapy were also asked to answer the ACL-QOL questionnaire, the Lysholm Knee Scale (LKS), Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and the short form 36 (SF-36) at pre-operative, 16th week and 2years post-operatively to assess responsiveness. The questionnaire had high internal consistency (Cronbach's α=0.95). The paired t test showed no significant difference between the test-retest means. The intraclass correlation was excellent for reliability and agreement in five domains and overall score (ICC 0.95, 0.95, 0.97, 0.95, 0.96 and 0.95; p<0.001). The standard error of measurement and the minimum detectable change (MDC95) were found to be 3.1 points and 8.7 points, respectively. The questionnaire showed a fair correlation (r=0.23) with LKS and a poor correlation (r=0.14) with KOS-ADLS; good and very good construct validity (r=0.51, r=0.62) with SF-36 physical component score and mental component score, respectively. No ceiling and floor effects were observed except the subdomain of 'work-related concerns' (22.9%). A dramatic effect size was demonstrated at the 16th week (2.1) and 2years (1.1) of follow-up. Turkish version of the ACL-QOL questionnaire is a reproducible and responsive instrument that can be used in clinical studies. Diagnostic study, Level I.

Translation and measurement properties of the Swedish version of ACL‐Return to Sports after Injury questionnaire

Psychological factors may be a hindrance for returning to sport after an anterior cruciate ligament (ACL) reconstruction. The ACL-Return to Sport after Injury scale (ACL-RSI) measures athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport. The aim of this study was to translate the ACL-RSI scale from English to Swedish and to examine some of the measurement properties of the Swedish version. The ACL-RSI was translated and culturally adapted. A professional expert group and five patients evaluated face validity. One hundred and eighty-two patients completed the translated ACL-RSI, a project-specific questionnaire, the Tampa Scale of Kinesiophobia (TSK), the Knee-Self-Efficacy Scale (K-SES), the Multidimensional Health Locus of Control (MHLC-C), the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaires. Fifty-three patients answered the ACL-RSI twice to examine reproducibility. The ACL-RSI showed good face validity, internal consistency (Cronbach's alpha = 0.948), low floor and ceiling effects and high construct validity when evaluated against the TSK, K-SES, MHLC-C, KOOS, and ACL-QoL scales. The reproducibility was also high (intra-class correlation = 0.893). Therefore, the ACL-RSI can be used to evaluate psychological factors relevant to returning to sport after ACL reconstruction surgery.

Augmentation of Femoral Fixation in Hamstring Anterior Cruciate Ligament Reconstruction with a Bioabsorbable Bead

Background The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. Hypothesis The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. Study Design Prospective single-blind randomized clinical trial. Methods ACL reconstruction with autogenous semitendinosus and gracilis tendons was performed on 35 patients. Preoperatively, 3 months, 6 months, and 18 months postoperatively, patients’ knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL Questionnaire. Results Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at 6 months and 18 months postoperatively; the mean side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences were not detected when comparing the ACL-QOL Questionnaire between the two groups at all time intervals. Conclusion The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to 18 months postoperatively in terms of KT-1000 side-to-side differences.